Sequel opportunities

Managers are bracing themselves for the outcomes of two major reviews of the NHS that seem set to rekindle the old debate about the internal market. Paul Stephenson reports The language may have changed but the idea is the same. One of Margaret Thatcher's most hated notions is back on the agenda.Yes, the internal market is rearing its ugly head once more.

Ex-Confederation of British Industry director general Adair Turner is heading a review of structures which will examine how acute trusts could be given greater freedom to pursue their earned autonomy. But the internal market has many negative connotations. So, instead, the review will examine capacity and contestability - in other words, diversity of providers and a contest for work.

The review is running in parallel with a Treasury review of NHS funding, headed by former National Westminster Bank group chief executive Derek Wanless.

This is expected to tell chancellor Gordon Brown that for the UK to continue with a high-quality, comprehensive NHS free at the point of need, much more money will have to be put into it.

Although it has been said that the Turner review is not about funding, it is understood the issue ofa hypothecated health tax, thought to be favoured by health secretary Alan Milburn, is being investigated somewhere.

The Turner review team has not been revealed, but sources say members of the Department of Health strategy unit, headed by Professor Chris Ham, are involved.

As well as looking at earned autonomy, the team is examining capacity and supply issues. What this means is not for public consumption. But policy analysts agree it ought to involve giving trusts greater freedom and radically altering how NHS staff work.

King's Fund health systems programme director John Appleby says of the Turner review: 'If you were considering an alternative, it could be an internal market. But given the climate I can't see that happening. One possibility may be to consider a more independent type of provider in the health service. You leave the purchaser side alone, funded through general taxation, and go for shaking up the hospital side and the primary care side.

'It may be that if earning autonomy is not going far enough, then one option is to go further down that line.'

Mr Appleby says you could have independent organisations, based on a not-for-profit model, 'where There is the power to borrow money and make decisions independently of government priorities'.

This idea is supported by Birmingham University health services management centre senior research fellow Dr Kieran Walshe.He says: 'I would welcome the review looking at the DoH and NHS organisations and the interaction between them.Would the NHS be better managed if we had a more plural system? You might think that one way of tackling the issues would be to find different ways that put them at arm's length from government.

One way would be to make the National Institute for Clinical Excellence and Commission for Health Improvement formally independent. One way would be to give trusts greater freedom.

'I think we should look at analogies in other areas of the public sector.You could think about universities. They are incorporated, but have a high degree of independence. We should be looking around the public sector for other models of management.'

Dr Walshe says one model could be of institutions that were directly answerable to Parliament, rather than through the DoH, 'a system in which there is more of a plurality and less bureaucracy'.

Liz Kendall, senior research fellow at the influential Institute for Public Policy Research, says: 'It would make sense if Mr Wanless was saying, this is what a highquality service would mean and this is what it would cost, and if Adair Turner said, how do you deliver it and what structures do you have on the ground?

'The issues are around diversity and greater contestability. Does having greater diversity help?

'If the government sets the objectives and if there is greater diversity, who provides services?

Different sorts of providers.'

NHS Confederation policy director Nigel Edwards says contestability implies a situation where there can be a competition within the private sector for management of providers.

He points to other models, including the idea of doctors' chambers, mooted by the British Medical Association recently. He says: 'There are three possible models: competing providers [the internal market]; management teams; and competing doctors with supporting technical staff.'

Mr Edwards says if there are not enough staff, competing providers will not be possible.

York University health policy group's Professor Alan Maynard says of the possibility of reintroducing some form of internal market: 'What they will do is to try to create it without Thatcher.' He adds: 'The dirty dozen [managers on probation at no-star trusts] are a good example of contestability.

You have to compete for your job.'

The other issue under review is capacity and how best to use staff.

The IPPR has started a major project on the role of the future health worker.

Ms Kendall says demarcation between staff has to be looked at.

'The government is renegotiating the GP and consultant contracts, but somebody has to look 10-15 years ahead.We have to go back to what are the core tasks and functions. It is about thinking about what is needed. That is not necessarily going to be the same in 1015 years' time.' She feels it has not been fully thought through. 'It is about looking at core competencies and who could do that.' She also raises the issue of staff moving between professions: 'People might not want to be a doctor or nurse all their lives. How do we enable easier movement between professions? That is the sort of thinking that could be done.'

Mr Edwards endorses the complete redesign of roles 'based on what the patient needs' to 'create new people'. He says we need to think about 'new roles in a way that we can train people in two to three years, rather than eight to nine.

The review of NHS funding for the Treasury has a remit to decide how much a high-quality, comprehensive service would cost over the coming years.

It is not likely to provide a percentage figure for how much spending will need to rise. But it will point out that the proportion of GDP spent on healthcare is converging to between 8-10 per cent in the developed world, as highlighted in a new Organisation for Economic Co-operation and Development report.

Mr Appleby says: 'The key things they are looking at are, what are the pressures to spend more? The key ones are changes in the population, changes in public perception, and IT and healthcare technology in general. In a sense they are looking at cost drivers, and can that provide a handle on spending? One of the things that Mr Wanless readily admits is:

what do you mean by comprehensive and clinical need? How high is high quality? That is the top and bottom of it. I think they are trying to get a ballpark figure.'

Dr Walshe says: 'The message is they are going to need more than the rate of inflation and economic growth, and that is going to have to come from somewhere. It is hard to believe that health spending is not going to rise to 8-10 per cent.'

The context of all the work going on is two-fold. The Treasury review aims to let the government know what it will all cost in time for the next comprehensive spending review. The Turner review is aimed at what needs doing if the NHS plan targets are not met. The crucial dates are 2004-05 when a general election is due and many targets have to be met.

A two-day conference starts in London today, organised by the Treasury review team, to discuss funding pressures. It will hear a summary of the issues. But the findings of the Turner review may not be so freely available.

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